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Medicare Has the Potential to Avoid Preventable Illnesses by Encouraging Broader Coverage for Adult Vaccines

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A new analysis by Avalere finds that, despite efforts by policymakers to encourage broader vaccination rates, Medicare enrollees have limited access to a set of 10 recommended vaccines without having to pay out-of-pocket (e.g., co-payments).

Avalere experts found that approximately 12 percent of enrollees in Medicare Advantage Prescription Drug (MA-PD) plans-4 percent of overall Medicare Part D enrollees-had access to these vaccines in 2016 without out-of-pocket costs, up from less than 5 percent in 2011. No standalone Part D plans (PDPs) covered any of these vaccines for diseases like Tetanus, Hepatitis A and Hepatitis B without out-of-pocket costs to the patient during the six years included in the analysis.

“Rates of vaccine-preventable illnesses are particularly high among older adults,” said Caroline Pearson, senior vice president at Avalere. “While most private insurance plans are now required to cover recommended vaccines at no cost to the patient, very few Medicare beneficiaries enjoy this same level of coverage.”

Federal policymakers have taken numerous steps to expand vaccination rates. Healthy People 2020, a national effort by the Office of Disease Prevention and Health Promotion, has a goal to increase immunization rates and reduce cases of these diseases. The Centers for Disease Control and Prevention issued recommendations on 17 vaccine-preventable conditions to help guide healthcare providers. The Affordable Care Act (ACA) also built on the CDC recommendations by requiring most health plans in the commercial market to cover vaccinations at no cost to the patient. Lastly, Medicare has encouraged Part D plans to adopt Vaccine Tiers with low cost-sharing amounts to promote broader access to vaccines for Medicare beneficiaries in Part D plans. In 2015, there were nearly 24 million beneficiaries enrolled in standalone PDPs and about 13.5 million beneficiaries in non-employer MA-PDs.

Avalere analyzed Medicare coverage trends from 2011 to 2016 for 10 vaccines that had age-specific recommendations for seniors or dealt with conditions for which seniors were a target population given their increased risks. The 10 vaccines and conditions included: Boostrix (Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed), Zostavax (Zoster Vaccine Live), Varivax (Varicella Virus Vaccine Live), Menomune (Meningococcal Polysaccharide Vaccine, Groups A, C, Y, W135 Combined), Havrix (Hepatitis A Vaccine), VAQTA (Hepatitis A Vaccine, Inactivated), Energix-B [Hepatitis B Vaccine (Recombinant)], RECOMBIVAX-HB [Hepatitis B Vaccine (Recombinant)], Twinrix [Hepatitis A Inactivated & Hepatitis B (Recombinant) Vaccine], and Tenivac (Tetanus and Diphtheria Toxoids, Adsorbed).

In 2015, there was a noticeable difference between the types of cost sharing that MA-PD plans used for the select vaccines compared to standalone PDPs. Approximately 80 to 90 percent of enrollees in MA-PD plans had a fixed-dollar co-pay for these vaccines, whereas between between 47 and 72 percent of enrollees in standalone PDPs were in plans that used a fixed dollar copay, depending on the drug.

“Medicare has an opportunity to encourage broader use of these vaccines through expanded coverage,” said Dan Mendelson, president of Avalere. “Options like including vaccine access in existing star ratings program may encourage more Medicare insurers to cover vaccines at no cost to the patient.”

The full report is available here.

GlaxoSmithKline provided funding for this analysis. Avalere Health maintained full editorial control, including selection of the vaccines, methodology, and content of the paper.


For purposes of this analysis, Avalere selected 10 vaccines that cover seven different conditions from the ACIP list of recommendations. We chose vaccines that either had specific over-age 65 recommendations or dealt with diseases for which seniors were a target population given their increased risks for the underlying condition. Part D formulary status is specific to the National Drug Code (NDC) for each drug or vaccine. A single drug or vaccine may have multiple NDCs that reflect differing dosages, strengths, route of administration, or other factors. We identified all of the NDCs for each of the 10 vaccines in our analysis from the list maintained by the Food and Drug Administration.

We used the Avalere DataFrame® to identify the tier placement for each of the NDCs in our analysis from 2011 through 2016. DataFrame® is a proprietary database maintained by Avalere Health that aggregates Part D formulary information and detailed drug data. We identified the specific tier placement for each plan in each year, including instances where plans did not cover the vaccine. Finally, we determined the total Part D enrollment for each plan as of July of each year.

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